Healthcare Provider Details

I. General information

NPI: 1013288448
Provider Name (Legal Business Name): KELLY MAE LOSINIECKI NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY MAE MCCARTHY

II. Dates (important events)

Enumeration Date: 01/17/2012
Last Update Date: 03/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N EDDY ST.
SOUTH BEND IN
46617-3096
US

IV. Provider business mailing address

211 N EDDY ST
SOUTH BEND IN
46617-2808
US

V. Phone/Fax

Practice location:
  • Phone: 574-237-9231
  • Fax: 574-204-6355
Mailing address:
  • Phone: 574-237-9231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71003885A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28176558A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: